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When To File An Employee Claim Form - Form 110

The Form 110 - Employee Claim should be completed whenever you think you are not getting the workers' compensation benefits you are entitled to. For example, your company or its insurance company has said it will deny your right to receive compensation benefits OR it has reduced or stopped payment of your compensation for reasons that you do not believe are fair.

Documentation, as required by 452 CMR 452 CMR 1.07: Claims And Complaints , must also be attached to the Form 110 -Employee Claim form. This documentation needs to be sent to the Department of Industrial Accidents (DIA) and the insurer. essentially, you need to attach any documentation that supports your claim, including medical reports.

If the claim is just for medical bills, you need to include copies of the bills to the DIA and the insurer.

NOTE: An attorney filing this form must send a copy to the insurer by certified mail in order to be entitled to an attorney's fee. MGL c. 1552, § 10(1).

The ONLY reason for completing this form is to request a judicial proceeding before an Administrative Judge, in order to obtain workers' compensation benefits from your employer's insurance company (or the Workers' Compensation Trust Fund if the employer was breaking the law by not having insurance).